A Comparative Analysis of State Implementation of the Community First Choice Program

Abstract

The Patient Protection and Affordable Care Act included Community First Choice (CFC), a new optional Medicaid home and community-based services (HCBS) state plan benefit which states could adopt. Through the CFC program, states can provide expanded home and community-based attendant services and supports to older adults and persons with disabilities. A benefit of CFC is that states receive a higher federal match rate than other HCBS programs. Thus far, eights states have adopted CFC. This comparative case study analysis examines state-level implementation of CFC to identify what facilitated implementation and what created challenges. The results suggest that consulting with the Centers for Medicare and Medicaid Services facilitated implementation while existing programs, insufficient engagement with stakeholders, aggressive timelines, and limited staff resources presented challenges. Based on these findings, states may want to consider how they approach implementing expansions or enhancements to HCBS benefits under the American Rescue Plan Act.

Keywords

home and community-based care and services long-term services and supports policy Medicaid

What this paper adds

This study adds to the literature on the implementation of Medicaid home and community-based services (HCBS) policies by comparing the CFC implementation experiences of multiple states.

Applications of study findings

This study provides lessons learned for other states looking to implement CFC or other Medicaid HCBS benefits under the American Rescue Plan Act.

This study suggests who should be involved in the implementation of HCBS programs including federal officials, state officials, and external stakeholders such as advocacy groups and provider representatives.

Introduction

The Medicaid program plays an important role in providing long-term services and supports (LTSS) including HCBS for older adults and persons with disabilities. Annually, spending for Medicaid HCBS is approximately $92 billion which provides services to over 2.5 million program beneficiaries (O’Malley Watts et al., 2020). These individuals rely on Medicaid HCBS programs to assist with activities of daily living such as bathing, dressing, and eating and instrumental activities of daily living such as shopping, meal preparation, and transportation.

States have a variety of options to provide HCBS through Medicaid. Under federal Medicaid regulations, all states must provide home health state plan services, and states can also elect to offer state plan personal care services which 34 states provide (O’Malley Watts et al., 2020). The most widely used Medicaid HCBS option is 1915(c) waivers which are attractive to states because of their flexibility. Under 1915(c) waivers, states can target benefits to specific populations (i.e., older adults or individuals with intellectual or developmental disabilities) and specific regions of the state, and also impose limits on the number of enrollees. 1915(c) waivers are the largest Medicaid HCBS benefit with respect to both number of enrollees and spending.

Over the last decade, federal and state policymakers have expanded options for Medicaid funded HCBS benefits. These efforts to increase HCBS options have been partly influenced by the desires of older adults to age in their own communities. Over three-fourths of older adults would like to continue living in their current residence as they age (Davis, 2021). The Patient Protection and Affordable Care Act (ACA) included several provisions that expanded Medicaid HCBS benefits including Community First Choice (CFC), the Balancing Incentive Program, and changes to the 1915(i) HCBS benefit. All these programs were optional with states deciding whether to adopt them.

The Community First Choice 1915(k) state plan option allows states to provide home and community-based attendant services and supports through the Medicaid state plan. Since CFC is a Medicaid state plan benefit, states adopting CFC must serve everyone eligible and cannot target CFC benefits to specific age groups, types of disabilities, or geographic regions. A key advantage for states to adopt CFC is an additional six percent (6%) federal match for these expenditures. CFC’s comprehensive services include assistance with activities of daily living, instrumental activities of daily living, health-related tasks, and back-up systems that ensure continuity of services such as personal emergency response systems. To receive these services, an individual must require an institutional level of care and have an income at or less than 150% of the federal poverty level. Individuals with a higher income level are eligible for CFC if they are receiving waiver services. Under the CFC state plan benefit, states can deliver services through agency providers or through a self-directed model in which the recipient is responsible for hiring, training, supervising, and firing his or her worker.

Thus far, eight states have elected to adopt CFC as an optional Medicaid HCBS benefit. These states are California, Connecticut, Maryland, Montana, New York, Oregon, Texas, and Washington. States could begin adopting CFC in 2011. California was the first state to submit its CFC state plan amendment to the Centers for Medicare and Medicaid Services (CMS). In fiscal year 2018, approximately 392,000 enrollees received services through CFC. California had the largest number of CFC enrollees at 228,000 while Connecticut had the fewest enrollees with 3,200 individuals (O’Malley Watts et al., 2020).¹ In fiscal year 2018, total expenditures for CFC were approximately $17.4 billion (Murray et al., 2021).

This research examines what factors facilitated or impeded implementation of CFC. Understanding implementation of HCBS programs such as CFC is critical because challenges or setbacks in implementation can hinder the attainment of federal and state government goals to rebalance the provision of long-term care services away from institutions towards home and community-based options. Previous research has examined the early adoption and implementation of CFC (Beauregard & Miller, 2021; Burgdorf et al., 2020). Factors that have influenced the adoption of CFC include the enhanced match rate, existing HCBS programs, and bureaucratic support (Beauregard & Miller, 2021; Burgdorf et al., 2020). The implementation of CFC has been influenced by communication with local stakeholders, sufficient staffing, and federal regulations (Burgdorf et al., 2020). The present investigation differs from these studies in several ways. First, other studies have examined states’ decisions to adopt CFC while the present study focuses exclusively on state implementation of the program. Second, the present study compares the implementation experiences of two very different states because common implementation challenges across states may be relevant for other states contemplating CFC. Lastly, individuals with a national perspective were also interviewed as part of the present study to identify factors influencing CFC implementation beyond the case study states.

The lessons learned from states’ implementation of CFC can have insights into the implementation of other HCBS programs. The American Rescue Plan Act (ARPA) includes a 10-percentage point increase in federal matching revenue for all HCBS spending for a 1-year period. Under this initiative, at least one state is planning on implementing CFC while other states are expanding or adopting other HCBS benefits (ADvancing States, 2021). In addition, like CFC, the Biden administration’s Build Back Better Plan includes a permanent 6 percentage point increase in federal matching funds for Medicaid HCBS spending. Therefore, the lessons learned from states’ implementation of CFC can inform ongoing HCBS policy development.

The policy implementation literature has several potential insights for this research on CFC implementation. Within the literature, top-down approaches stress the importance of authoritative decisions for successful policy implementation while bottom-up approaches emphasize the role of street-level bureaucrats and target populations (deLeon & deLeon, 2002; Matland, 1995). Many early conceptual frameworks of policy implementation use a top-down approach and underscore the importance of policy clarity and communication from decision-makers to the implementing agency (Sabatier & Mazamnian, 1980; Van Meter & Van Horn, 1975). Based this approach, clear objectives from federal officials may be important for successful implementation (Meier & McFarlane, 1995; Sabatier & Mazamnian, 1980; Van Meter & Van Horn, 1975). In addition, implementation research from a top-down perspective suggests that polices that make modest changes and are generally consistent with existing policies are easier to implement than policies that require substantial changes from the status quo or organizational change (Van Meter & Van Horn, 1975).

In contrast, bottom-up approaches to policy implementation start with individuals and groups at the local level. Once a policy is adopted, local individuals and organizations at the respond to the policy and devise their own implementation plans to fit local conditions (Berman, 1978). Street-level bureaucrats and others at the local level shape and change the implementation process in ways central decision-makers cannot envision and control (Lipsky, 1980). Therefore, if the same policy is implemented in multiple jurisdictions, the implementation process and outcomes can vary even if the central actors, policy language, and implementation resources are the same across jurisdictions. Consistent with bottom-up approaches, more recent literature has examined the role of stakeholder groups in policy implementation. According to Ansell et al. (2017), there needs to be collaboration among stakeholders during policy design and continuous collaboration and adaptation during implementation. Other research has focused on identifying the key stakeholder groups involved in policy implementation including interest groups, bureaucrats, political leaders, beneficiaries, and non-profit organizations (Campos & Reich, 2019; Daniel & Fyall, 2019).

Other studies have examined the implementation of Medicaid programs and HCBS policies and have identified specific factors that can influence the implementation process. Research on Rhode Island’s implementation of the Medicaid 1115 Global Waiver suggests that insufficient experienced staff within the state bureaucracy impeded implementation (Miller, 2014). In addition, previous research on Maryland’s implementation of CFC suggests that staffing posed a challenge to implementation (Burgdorf et al., 2020). Success implementing the Veteran-Directed HCBS program partly depended on the communication between the local VA and Aging and Disability network agencies and a contact at the VA who championed the program and was involved in the program development (Thomas & Allen, 2016). According to Thompson and Burke (2009), the federal government provides state with substantial autonomy to operate 1915(c) Medicaid HCBS waivers but imposes more federal requirements when states operate 1115 waivers. The implementation literature identifies many factors that may influence states’ implementation of new HCBS programs, and it is not clear which approach and factors deriving from the top-down or bottom-up literatures may best account for implementation of CFC. This research seeks to identify what factors were most important in states’ implementation of this program.

Design and Methods

This study used comparative case studies to explore states’ implementation of CFC. Comparative case studies ask similar questions across each case to allow for cross-case comparisons (George & Bennett, 2005). The most different case method was applied to select the case study states (George & Bennett, 2005). When studying policy implementation, the most different case study design is beneficial because implementation research is often plagued by many factors that contribute to implementation performance. The most different case design allows for a narrowing of potential explanatory factors of policy success or failure (Goggin, 1986). Using this approach, the two selected states both implemented CFC but differed in many other respects including political ideology, state wealth, and LTSS characteristics. The two states selected were Maryland and Texas. Both states adopted CFC, but Maryland is politically more liberal and has higher per capita income, while Texas has more nursing facility beds and home health agencies per capita.

Qualitative data was primarily collected through interviews. Interviewees from Maryland and Texas spoke about the successes and challenges of implementing CFC in their respective states. In addition to interviews with representatives from these two states, interviews were also conducted with individuals from a national perspective who were familiar with other states’ implementation of CFC. These interviewees could speak more broadly about the relevant factors of states’ implementation of CFC. Interviewees included national officials; national advocacy organizations; other policy experts; officials in both the bureaucracy and legislature of the state; and members of state-level interest groups including provider and consumer advocacy organizations. Interviewing individuals both within and outside of the federal and state governments and individuals representing different HCBS advocacy groups, including older adults, individuals with intellectual and development disabilities, and individuals with physical disabilities, helped ensure that many perspectives were represented (Glaser & Strauss, 1967).

The interviews were conducted by telephone and were recorded with participants’ consent. The interview protocol, which is available as supplemental material, asked questions about how states approached implementing the program, what facilitated or impeded implementation, what was learned during implementation, and what impact did CFC have. Specific questions included “who was involved in implementing the CFC program,” “were there things that facilitated the implementation of CFC,” “did your state encounter any challenges or setbacks getting the program going,” “is there anything that could have been done differently in implementing CFC,” and “what impact do you think CFC had on LTSS in your state.” This research was approved by the University of Massachusetts Boston Institutional Review Board.

To identify and recruit interviewees, a combination of purposive and snowball sampling was used. First, individuals familiar with HCBS polices and CFC nationally and within each state were identified. During the interviews, interviewees were asked to identify other potential interview subjects. Interviews were conducted between September 2016 and January 2018. In total, 37 individuals were interviewed, including 9 national interviewees, 14 from Texas, and 14 from Maryland. The number of interviewees by state and type of interviewee is shown in Table 1.

Table 1.

Interviewee Types.

Interviewee Type	Maryland	Texas	National
Government bureaucrat	4	5	3
Consumer advocate	6	5	2
Advocate for state governments	—	—	2
HCBS provider	1	3	—
Consultant	2	1	2
Legislator	1	—	—

The transcripts of the audio recordings were coded with NVivo 12 using a coding process that was both deductive and inductive. An a priori coding scheme was developed prior to data collection based on the literature. This a priori scheme was used to initially code all the interview transcripts, and new concepts emerged based on the interviews (Rubin & Rubin, 2005; Saldana, 2012). The coding scheme was reorganized to incorporate new codes, merge redundant codes, and delete codes that were not pertinent. The initial coding scheme was based on the broader implementation literature as well as specific factors that influenced HCBS or Medicaid policy implementation in previous work. Concepts that drew from top-down approaches included the federal government, CMS, and existing HCBS programs (Van Meter & Van Horn, 1975; Sabatier & Mazamnian, 1980). From a bottom-up perspective and the HCBS and Medicaid implementation literature, concepts included interest groups such as consumer advocates, provider representatives, and local authorities (Berman, 1978; Miller, 2014; Thomas & Allen, 2016).

All the transcripts were coded using the final coding scheme which was grouped hierarchically into themes, categories, and codes. Examples of themes include broad categories such as “interest groups,” “economic/fiscal factors,” “existing LTSS policies,” and “external factors.” The categories were more specific and included “consumer advocates,” “managed care,” and “federal government.” The codes narrowed the categories and indicated specific policies, programs, organizations, or concepts (i.e., HCBS waiver, CMS, and provider rates).

Documents were also reviewed relating to the implementation of CFC. These documents included Maryland and Texas’ CFC state plan amendments, press releases, frequently asked questions documents, and PowerPoint presentations. These documents were obtained by conducting web searches pertaining to CFC and asking interviewees if they had any documents that they would be willing and able to share. The findings that follow are based on the key informant interviews. The document reviews provided background information on each state’s HCBS system and specific aspects of CFC. In addition, the documents confirmed some of the assertions made by the interviewees.

Results

Maryland and Texas submitted their CFC state plan amendments to CMS in 2013 and 2014, respectively. Maryland pursued CFC to consolidate services from three existing programs: the State Plan Medicaid Assistance Personal Care program, the Living at Home Waiver, and the Older Adults Waiver. The aim was to better ensure consistency across HCBS offerings. While individuals in all three programs could have similar acuity levels, the level of services provided varied substantially across programs. Texas pursued CFC to provide personal care and habilitation services to individuals on a waiting list for intellectual disability and developmental disability waivers. Texas elected to allow individuals to self-direct their CFC personal assistance services or habilitation through a Consumer Directed Services option. In Texas, CFC is available through Medicaid managed care organizations and waiver programs. Individuals not enrolled in a 1915(c) waiver receive CFC services through a managed care organization while individuals in a waiver receive CFC services through their comprehensive waiver provider.

Facilitators of Policy Implementation

Communication with Centers for Medicare and Medicaid Services

Prior to implementing CFC, states needed CMS to approve their CFC state plan amendment. In both Maryland and Texas, state officials recognized the value of consulting with CMS throughout the process. In Maryland, state bureaucrats appreciated that officials from CMS were willing to work with them on the development of their CFC program. According to a Maryland Medicaid state bureaucrat, “I think CMS was really available to us which I think was really important … I think it’s really helpful to have their input and their feedback and kind of work as a team.” With Texas’ CFC state plan amendment, CMS also worked closely with the state to ensure their final submitted state plan amendment was approvable and that the approval happened in a timely manner. According to a Texas state bureaucrat, “CMS was really great working with us as we developed the SPA [state plan amendment]. We sent it back and forth a million times before we actually submitted it and got feedback from them.” By engaging with CMS early, Texas expedited the state plan amendment approval process and ensured that the program design met federal requirements.

Leveraging existing home and community-based services infrastructure and providers

Most states that pursued CFC moved existing HCBS offerings, such as state plan personal care or waiver services, to CFC. Transitioning existing programs had both benefits and, as discussed next, drawbacks. State officials tried to make the transition to CFC as seamless as possible to enrollees and providers. According to a few interviewees in Maryland and Texas “I think most participants probably don’t even know what has happened” (Maryland consultant) and “we tried to make it pretty much invisible for the clients … the providers had to change the way they billed slightly but overall it was supposed to just be just sort of a money swap on the backend” (Texas Medicaid bureaucrat). Leveraging existing HCBS infrastructure and provider networks facilitated states’ implementation of CFC.

Barriers to Policy Implementation

Enrollment requirements created administrative burdens

While existing HCBS programs facilitated CFC implementation in some respects, they also posed challenges for states in other ways. One challenge faced by CFC states was the need to continue to ensure that some CFC enrollees received waiver services to maintain eligibility for CFC. At a minimum, states generally must provide Medicaid to Supplemental Security Income (SSI) recipients. States also have options to increase Medicaid income eligibility for older adults and persons with disabilities, including up to 300% of the SSI amount, under the special income rule. CFC enrollees who were eligible for Medicaid under the special income rule need to continue to receive at least one waiver service per month or they would lose their Medicaid eligibility and therefore be ineligible for CFC. According to several national interviewees, “if you put people in CFC who were previously in a waiver … you’re going to have to keep them in the waiver so that you can have them in CFC. Then it’s … very difficult to track” (federal bureaucrat) and “you see states having to play some fun games by keeping essentially a shell of 1915(c) waiver open in order to continue eligibility for people so they don’t get kicked off of Medicaid because their service is moved into a 1915(k) [CFC]” (national aging advocate). In both quotes, the national interviewees identify a challenge with CFC in that individuals who are eligible for the program by virtue of their waiver services must continue to receive waiver services otherwise they will no longer be eligible for CFC.

Provider payment rate issues

Another challenge both Maryland and Texas faced implementing CFC related to variation in provider payments rates that existed across programs prior to CFC. Before adopting CFC, Maryland had different rates for the waiver programs and state plan personal care program with the later receiving lower rates than the former. According to a Maryland Medicaid state bureaucrat, “some people, depending on what program they were in, were now going to be getting a higher rate and there were some people that saw a rate cut.” In addition, in Texas different rates existed between intellectual disability/developmental disability providers and personal care providers. According to several consumer advocates and provider representatives, receipt of lower CFC rates has been a challenge for intellectual disability/developmental disability providers. Noted a provider representative, “the rate that was offered was substantially lower than what we had initially discussed and anticipated … so that really created a barrier for intellectual disability/developmental disability providers in particular participating in the program.” An intellectual disability/developmental disability advocate agreed, “people on the developmental disability side have sustained a 21% rate reduction and will probably have another one.” These quotes highlight that intellectual disability/developmental disability providers experienced a substantial rate cut, and the CFC rate was significantly lower than expected. In turn, the low payments rates in CFC had an impact on the availability of providers. According to an aging advocate in Texas, “the provider rates are incredibly low. Even if CFC services are authorized, it’s really difficult to find qualified providers because of the low reimbursement rates.”

Budget overruns for preexisting home and community-based services programs

Another issue Texas encountered was budget overruns from moving personal assistance services and habilitation services from 1915(c) waivers into CFC to take advantage of the 6% additional match on CFC services. When implementing CFC, Texas moved a subset of services from 1915(c) waivers to CFC, but many waiver participants remained in the waiver to continue receiving other services not covered by CFC. Officials in Texas “had not anticipated that people currently receiving services would be now eligible for significantly more [under CFC] than what they had been receiving” in the waivers according to a provider representative. The expansion of services for individuals served through both the waiver and CFC created budgetary challenges for the state. According to one state bureaucrat in a disability agency, “a major unintended consequence [was] that the waiver cost … just spiraled and we had to immediately stop enrollment into that waiver because the people that were already in it were suddenly starting to get a lot more services.” The state bureaucrat highlights that state officials did not anticipate that service costs for individuals enrolled in that specific waiver would increase due to CFC and, to control costs, the state stopped enrolling individuals in the waiver.

Aggressive timelines

The implementation timeline for CFC was aggressive given the extent of the change required, consuming a large amount of state staff time in the Medicaid and disability services agencies. Interviewees in both Maryland and Texas acknowledged that implementing CFC was a monumental task. According to a state bureaucrat in Maryland’s Medicaid agency, it was “a pretty heavy lift … The new tracking system went up, budgets were calculated based on the RUGs [resource utilization group] budget, services were covered under Community First Choice instead of the waiver … Hindsight’s 20/20 so it was a rough period … but I don’t know that we could’ve really separated out many of those changes or I don’t know that we could’ve piloted them or rolled them out any differently.” In Maryland, the state was using funding from the Balancing Incentive Program for implementation of CFC. The Balancing Incentive Program was temporary, and states had deadlines within which to expend the funding. Several interviewees in Texas also conveyed that the amount of work in transitioning existing waivers and state plan services to CFC was considerable. According to two Texas state bureaucrats, “we had to just touch so many different systems and so many different authorities and every waiver had to be amended and every set of rules about every program had to be amended” and “our biggest challenge was the timeline. It was a massive [undertaking].” In both Maryland and Texas, therefore, implementing CFC required substantial changes to existing LTSS systems and processes.

Limited staffing resources

Since implementing CFC was a large undertaking, state staff in both Maryland and Texas needed to focus on rolling out CFC, often to the exclusion of other responsibilities. During this transition to CFC, state employees’ time needed to be redirected from their normal responsibilities to focus on CFC implementation. According to interviewees in Maryland, “we ended up getting permission to hire a bunch of temporary emergency staff just because we didn’t have the staffing level necessary … So it definitely would’ve been better if we’d had more staff when that happened” (state Medicaid bureaucrat) and “I didn’t think they have enough staff then. I don’t think they have enough or the right, or qualified, or experienced enough people now” (physical disability consumer advocate). The implementation of CFC in Texas also involved multiple agencies within state government and a substantial amount of staff time. According to a Texas state bureaucrat, the implementation of CFC “involved three agencies and staff had to just go completely on to CFC and not do their other work.”

Insufficient engagement with stakeholders

Maryland encountered issues implementing CFC because external stakeholders were not sufficiently engaged in the process. According to one national consultant, “doing outreach, training across the state, making sure they’ve got sufficient partners in the implementation” was important for CFC implementation success; however, interviewees in Maryland indicated limited engagement in their state. As part of CFC, a state must establish a Development and Implementation Council. The purpose of Council is to inform the design of the state plan amendment and its membership includes individuals with disabilities, older adults and their representatives. While officials in Maryland sought input through their CFC implementation council, external stakeholders hoped state officials would be more receptive to feedback from council members. In implementing CFC, several interviewees in Maryland indicated insufficient communication and collaboration with external stakeholders. According to a Maryland Medicaid state bureaucrat, “I think that if that [stakeholder engagement] had been clear at the beginning, that would’ve really improved a lot of things ‘cause I think there was a lot of confusion and hesitation and fear and frustration.” Reported a physical disability advocate, “they [state officials] sort of just stopped taking any input or taking your input with a smile on their face and then turning around and doing whatever the hell they wanted was very much how it felt.” Said another physical disability advocate “the [Development and Implementation Council] was unanimously opposed [to eliminating the self-directed option] and said all kinds of comments … and the state went ahead and did it anyway.” In the above quotes, both advocates emphasize that while the state of Maryland accepts feedback from stakeholders, this feedback had little impact on policy decisions. Representatives of key stakeholders thus felt as if state officials in Maryland did not adequately consider their input during the implementation process.

Discussion and Policy Implications

With CFC both Maryland and Texas undertook substantial changes to their states’ HCBS offerings. Communication with CMS facilitated each state’s implementation of CFC. In addition, Maryland and Texas leveraged existing HCBS infrastructure and, when feasible, sought to make the program changes largely invisible to enrollees. States encountered several challenges implementing CFC. One challenge arose from administrative burdens associated with ensuring that enrollees did not lose their Medicaid eligibility. Both Maryland and Texas also encountered challenges with CFC provider payments rates, and Texas faced higher than anticipated costs. Ambitious timelines, limited staff resources, and communication with external stakeholders also presented challenges for Maryland and Texas. As states are enhancing HCBS benefits with the ARPA funding, the lessons learned from implementing CFC can have important policy implications.

Close collaboration between CMS and state officials facilitated the development of states' CFC state plan amendments. State officials from both Maryland and Texas spoke highly of working closely with officials from CMS when developing the program. Future federal programs should include close engagement between federal and state officials. When federal and state officials communicate frequently, they can ensure that the states are aligned with federal requirements and that a state’s Medicaid state plan amendment will be approved by CMS. Other states that are contemplating adding CFC would benefit from engaging with CMS early in the process.

The findings from this research are also consistent with bottom-up approaches to policymaking, which emphasize the implementation process at the local level and the importance of communication among implementation partners (Berman, 1978). Interviewees conveyed that the implementation process could have gone smoother if state officials better engaged and communicated with non-governmental and local stakeholders. Although federal regulations require each state to have a Development and Implementation Council comprised of stakeholders during the development and implementation of the CFC state plan benefit, state-level stakeholders in Maryland did not always feel this council had meaningful input. Consistent with previous research on CFC and Veteran’s HCBS benefits, this suggests that communication with external and local stakeholders is important in the implementation process (Burgdorf, et al., 2020; Thomas & Allen, 2016). While CMS encourages states to engage stakeholders in the development and implementation of policies and programs, this is not a requirement in the case of ARPA as with CFC. Nevertheless, the implementation process may go smoother if non-governmental stakeholders have opportunities for meaningful involvement.

Existing HCBS programs presented both facilitators and barriers for states when implementing CFC. In Maryland and Texas, the CFC program was generally consistent with current offerings. Many of the individuals enrolled in CFC were already receiving services through existing programs and many of the providers were already Medicaid HCBS providers. Both states sought to make the transition as seamless as possible for enrollees and providers when moving to CFC. Maryland and Texas, however, also experienced challenges implementing CFC because of the preexisting HCBS programs that they were offering. Issues both states encountered included administrative burdens associated with ensuring maintenance of enrollee eligibility and disparities in payments rates paid to providers across programs. In addition, Texas experienced an unexpected increase in waiver participants’ service plan costs when moving to CFC. Overall, these findings suggest that existing HCBS programs can facilitate the implementation of new HCBS programs in some respects but also complicate the implementation process in other ways.

Based on these findings, state officials should carefully consider the potential impact of pursuing new policies on existing HCBS programs. Adopting new HCBS programs can have unintended consequences for existing programs, budgets, and participants. When planning for implementation, states should evaluate all aspects of existing programs that would be affected by the new program. For example, when implementing the CFC, states needed to consider the impact of transitioning 1915(c) waiver enrollees who qualified under the special income rule; otherwise, these individuals could risk losing their Medicaid coverage and HCBS. In addition, when combining several existing programs into CFC, some providers of services experienced rates decreases. Adding new programs can have unforeseen impacts on existing programs and participants, and states should seek to mitigate these negative impacts to the extent possible.

Lastly, this study suggests that the competence and size of agency staff can facilitate the implementation process (Burgdorf et al., 2020; Miller, 2014; Van Meter & Van Horn, 1975). This research highlights the importance of sufficient and knowledgeable state-level staff in implementation of CFC and is consistent with previous research on CFC in Maryland and other Medicaid programs (Burgdorf et al., 2020; Miller, 2014). Both Maryland and Texas, for example, could have benefited from additional manpower; this is indicated by the need for state staff to defer other responsibilities when devoting time to implementing CFC. When implementing the ARPA funding, several states have indicated that they plan on adding additional state staff to assist with the implementation of this large initiative (ADvancing States, 2021).

Limitations

This study has several limitations that should be noted. One limitation was that some individuals knowledgeable about CFC either were not identified or did not consent to participate in an interview. These interviewees may have been able to contribute additional information about the implementation process. A second limitation was that when the interviews were being conducted states were still working through some of the implementation issues. CMS approved Maryland’s CFC state plan amendment in 2014 and Texas’ in 2015. Since both Maryland and Texas were still working on implementing these programs, there may be barriers or facilitators to implementation that the states experienced after this research was conducted. Moreover, the two states may have resolved some of the barriers they encountered early in the implementation process. Finally, this study examined the implementation process of one specific program in two states. Consequently, the findings may not be transferable to other states and HCBS programs.

Conclusion

The CFC program is an option for states to provide HCBS benefits to older adults and persons with disabilities under the Medicaid state plan. Since authorized under the Affordable Care Act, eight states have added this benefit. This research examined the implementation of CFC in two states to inform the implementation of future HCBS programs. The findings suggests that when implementing HCBS benefits states should work closely with CMS, carefully consider the impact on existing HCBS benefits, engage with external stakeholders, and have sufficient state-level staff. Based on these findings, states may want to consider how they approach implementing expansions or enhancements to HCBS benefits under the American Rescue Plan Act.

Supplemental Material

Supplemental Material - A Comparative Analysis of State Implementation of the Community First Choice Program

Supplemental Material for A Comparative Analysis of State Implementation of the Community First Choice Program by Lisa Kalimon Beauregard and Edward Alan Miller in Journal of Applied Gerontology

Footnotes

Declaration of Conflicting Interest

Lisa Kalimon Beauregard is an employee of the Commonwealth of Massachusetts Executive Office of Elder Affairs. This research was conducted independently from the Commonwealth of Massachusetts and the findings and conclusions contained within are those of the authors and do not necessarily reflect official positions or policies of the Massachusetts Executive Office of Elder Affairs.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the University of Massachusetts – Boston Doctoral Dissertation grant program and the John W. McCormack Graduate School of Policy & Global Studies Department of Public Policy and Public Affairs.

IRB Protocol

University of Massachusetts – Boston 2016124.

ORCID iD

Lisa Kalimon Beauregard

Supplemental Material

Supplemental material for this article is available online.

Note

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